Information Collection

FCC Form 497

IC 218852 under ICR 201711-3060-002 · OMB 3060-0819.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-0819 can be found here:

Documents and Forms

Document Name Document Type
PRA enrollment application fields final 092217.docx Other-Decription of Application Fiel
PRA for NLAD Reimbursement final 092217.docx Other-Description of Lifeline ETC Re
PRA for universal one-per-household fields final 092217.docx Other-Description of One-Per-Househo
PRA lifeline recertification form fields final 092217.docx Other-Description of Recertification
FCC Form 497 Instructions_Final_7-11-16.docx Instruction
FCC 5631 Lifeline Program Household Worksheet LI_ProposedFCC-WorksheetForm5631-10042017.pdf Form
FCC 5629 Lifeline Program Application Form LI_ProposedFCC-ApplicationForm5629-10192017-OMB.pdf Form
FCC 5630 Annual Recertification Form LI_ProposedFCC-RecertificationForm5630-10192017-OMB.pdf Form
FCC 497 Description of Services Requested and Certification - Fi Lifeline Form 497 Field Descriptions Final-Cean 071216.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	FCC Form 497	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 47 CFR 54.400-54.423 47 CFR 54.201-54.207

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Decription of Application Fields			PRA enrollment application fields final 092217.docx	Yes	Yes	Fillable Fileable Signable
Other-Description of Lifeline ETC Reimbursement Data Fields			PRA for NLAD Reimbursement final 092217.docx	Yes	Yes	Fillable Fileable Signable
Other-Description of One-Per-Household Worksheet for Lifeline Program			PRA for universal one-per-household fields final 092217.docx	Yes	Yes	Fillable Fileable Signable
Other-Description of Recertification Form for Lifeline Program			PRA lifeline recertification form fields final 092217.docx	Yes	Yes	Fillable Fileable Signable
Form	FCC 5631	Lifeline Program Household Worksheet	LI_ProposedFCC-WorksheetForm5631-10042017.pdf	Yes	Yes	Fillable Fileable Signable
Form	FCC 5630	Annual Recertification Form	LI_ProposedFCC-RecertificationForm5630-10192017-OMB.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			FCC Form 497 Instructions_Final_7-11-16.docx	Yes	Yes	Fillable Fileable Signable
Form	FCC 497	Description of Services Requested and Certification - Field Descriptions	Lifeline Form 497 Field Descriptions Final-Cean 071216.docx	Yes	Yes	Fillable Fileable Signable
Form	FCC 5629	Lifeline Program Application Form	LI_ProposedFCC-ApplicationForm5629-10192017-OMB.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records
Title: FCC/WCB - 1, Lifeline Program	FR Citation: 82 FR 38686

Number of Respondents: 10,047,179	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	11,977,061	312,830	11,664,231
Annual IC Time Burden (Hours)	5,514,285	-559,790	6,074,075
Annual IC Cost Burden (Dollars)	468,750	0	468,750

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.